Transcript Cogito ergo sum’ - Azienda USL di Reggio Emilia

Philip Thomas
Patience Seebohm
Salma Yasmeen
Patrick Bracken
With thanks to Jennifer Davis, Sasha Bhatt, Kulvinder Kaur and
Shabana Kauser
1.
2.
3.
4.
Why public / user / community participation
in health is important – demographic and
policy contexts
What is community development? The work
of Sharing Voices Bradford
Community participation in outcomes and
commissioning – pitfalls and opportunities
Conclusions: bottom up vs. top down
 Community
and identity
 A community is a group that has a common
identity through:
•
•
•
•
living in a geographical area or neighbourhood
sharing faith/religious/linguistic features in common
sharing national, ethnic, social class or political identity
having a shared history, for example, colonialism
(hence South Asian, African-Caribbean)
• stigmatisation (e.g. the service user community)
 Or
any combination of these
 Globalisation
and increasing complexity of all
our identities (Bibeau, 1997)
 Multiculturalism, liberal democracies and
autonomy (Kymlicka, 1995)
 Multiculturalism and social cohesion – 9/11
and 7/7
 The problem of autonomy (Modood, 2007)
 Multiculturalism – integration and cohesion vs
recognising and respecting difference
10
9
8
7
6
5
4
3
White (92.1%)
Asian / British
Asian (4%)
Black / Black
British (2%)
Mixed (1.2%)
Chinese (0.4%)
2
1
0
Other (0.4%)





Rate of detection of significant mental health problems in
Black and South Asian people about half that of White people
in primary care.
Higher rates for admission to psychiatric hospital for AfricanCaribbean than White patients (South Asians catching up)
Rates of admission for African-Caribbean men are 3 to 13
times higher than White men
Black & Asian mentally disordered offenders have higher rates
of schizophrenia
African-Caribbean men and women over-represented in
forensic units, on remand and in prison
National Contexts: Stephen Lawrence
September 13, 1974 – April 22, 1993
 to
eliminate unlawful racial discrimination
 to promote equality of opportunity between
persons of different racial groups
 to promote good relations between persons
of different racial groups
 Places public authorities under an obligation to
engage positively with BME communities, and
to tackle social exclusion and discrimination.
 Race Equality Impact Assessments
NSC NHS Strategic Health
Authority (2003)
Independent Inquiry into the
death of David Bennett: An
Independent Inquiry set up
under HSG (94)27.
http://www.nscha.nhs.uk/scr
ipts/default.asp?site_id=117
&id=11516
 Delivering
Race Equality, 2005. Four elements:
• More appropriate and responsive services
• A more culturally diverse workforce
• Better information (Count me in)
• Community Engagement/Development, supported by 500
new community development workers
Trusts – recruit up to 1% of the
communities they serve as members / governors
 World Class Commissioning
 Foundation
UK – Quaker movement (18th century), socialism
and humanism (19th century), community
development and social work (20th century)
 International
 In
• Ghandi’s South African Ashram
• Utopian communities, Oneida (US) John Humphrey Noyes
1848 , New Australia movement Paraguay William Lane,
1892)
• Tanzania, Julius Nyerere and Ujamaa (familyhood)
• Paulo Freire – Pedagogy of the Oppressed
 Community
development and social capital
 Understanding
community strengths, beliefs and values
 Mapping needs and resources
 Working in partnership with local groups / organisations
 Community empowerment, increased participation in
decision making forums, facilitating community
enterprise
 Community involvement in service delivery
 Working inside, alongside and outside statutory services
 CD and communicative space (Habermas)
Bradford - main religious groups 2001
60
Christian
50
40
Per-cent 30
20
10
0
Muslim
Other (Sikh, Hindu,
Jewsih, Buddhist)
None / none stated
 Inner-city
Bradford; 60% of community from
BME communities; Largely South Asian
 1999 – closure of TCPU
 2000 – NHS reorganisation; Bradford City
tPCT
 How do services meet the needs of the city’s
BME communities?
 The role of Community Development

2002 project funded by PCT

Manager and 2.5 full-time equivalent CDWs (S Asian women, S
Asian men, A/C people)

Project based in the community, managed independently of
statutory services

Community mapping and community networking

2004 becomes independent charity

2004-2005 evaluation

2007 (DRE/FIS) 4 more CDWs (young people, older people,
Refugees and Asylum Seekers, Eastern European)
Outcomes & Commissioning Project: Aims
1. To involve people from BME communities in
developing an outcomes-focused commissioning
framework for mental health.
1. To develop a model for participation which enables
people from BME communities and mental health
service commissioners/ providers to work together in
future.
1.
Project manager DRE / FIS
2.
Commissioners: led by mental health, involving others at
the PCT, LA, GP alliances
3.
Local people from BME communities
4.
Providers: BDCT, LA, GPs, PCT, VCS (senior
management and front line practitioners)
5.
Academic support & facilitation: UCLAN
UCLAN Training & review of
framework & model:
commissioners & 4 participants
Community research:
9 participants, VCS
Consultations
with partners &
stakeholders
Policy & Participation
course with UCLAN:
24 BME participants
Develop framework:
2 commissioners,
2 participants &
UCLAN
Develop model of
participation:
UCLAN,
9 participants,
4 VCS staff/CDWs
 24
research participants recruited from 9 BME
community groups
 One third had used mental health services
 One third were carers
 One third asylum seekers / experience of
domestic abuse
 9 research participants carried out focus groups
with > 100 people from diverse communities
‘The study of a social situation carried out by
those involved in that situation in order to
improve both their practice and the quality of
their understanding’
Richard Winter and Carol Munn-Giddings, 2001
PAR as a research style rather than a method
PAR and mixed methods
PAR and organisational change
 Recognition
of expertise of those involved:
communities, commissioners, providers.
 Regular
reviews with participants to inform
research process & contribute to learning of what
works.
 Reviews
with wider interested groups to refine
framework and model.
 Outsider
roles: facilitation & academic support
(UCLan) for direction chosen from within.
“…in which people encounter each other reciprocally…
together seeking understanding and consensus…
speaking freely and opening themselves up to creative,
responsive, democratic approaches to problems”
(Kemmis, 2006)
1.
Capacity issues
2.
Divisions and hierarchies
3.
Models of mental health & power issues
4.
Pressures of family, health, work & time
1.
2.
3.
4.
5.
Complexity of the topic(s) & ability to cope
with the unfamiliar (all participants).
Statutory services unaccustomed to 2 way
dialogue.
English language skills and jargon (trialogue)
Skills in meetings: listening, being effective,
democratic and considerate.
Limited financial and administrative resources.
1.
Gender, age, faith, ethnicity, class, and
language.
2.
Community v community.
3.
Community & VCS v statutory sector.
4.
Statutory v statutory (LA, Trust, PCT).
5.
Management v practitioner.
1.
Medical dominance & focus on risk in statutory
services.
2.
Social, spiritual, economic dominance & focus
on choice in community sector.
3.
4.
Commissioners’ scope to increase choice limited
by the block grant – i.e. funding to statutory MH
services.
Practitioners scope to offer non-medical
approach limited by circumstances of job.
1.
2.
3.
Senior staff fail to turn up due to pressures of
work
Participants fail to turn up due to pressures in
the home or health
Limited capacity to support participants and
organise reviews due to pressure of time for
project team.
1.
Practical measures
2.
Experiential learning
3.
Tools for the future
1.
2.
3.
4.
5.
Recruiting across many communities.
Recognition through pay for work done,
childcare and travel.
Shared food, community venues.
Expert training in public speaking,
opportunities to practice.
One to one support, group discussions.
1.
2.
3.
4.
Training together, with senior staff.
Learning about different groups
through research.
Discovering commonalities across
communities.
Gaining awareness of own and other’s
strengths and weaknesses during the
project
1.
The commissioning framework
a.
b.
2.
recognises similarities & caters for difference
Recognises the individual’s right to choose the
healthcare they want.
The model of participation
a.
b.
promotes community cohesion
Potentially increases the influence of BME
communities v provider organisations.
1.
2.
3.
4.
How much will be funded?
If the model of participation is not funded, can a
communicative space (Habermas) be sustained?
Without a communicative space, can the shared
commitment, community cohesion &
community influence be sustained?
Multiculturalism in Mental Health Provision
– integration and cohesion vs respecting
diversity
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(Seebohm, P. et al (2005) Together we will change. London,
SCMH.
Thomas, P., Seebohm, P., Henderson, P., Munn-Giddings,
C. & Yasmeen, S. (2006) Tackling Race Inequalities:
Community Development, Mental Health and Diversity.
Journal of Public Mental Health, 5, 13-19.
Bracken, P. & Thomas, P. (2005) Postpsychiatry: Mental
Health in a Postmodern World, in International
Perspectives on Philosophy and Psychiatry (Series
Editor Bill Fulford). Oxford, Oxford University Press.